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JOBSITE SAFETY WORKSHEET <br />Location ;� , l,�j <br />Lead R. F,>116,r <br />I Pre -Job Briefing Time / <br />Description of Work: <br />sev �r7�s <br />Safety Incidents & Concerns: <br />YES <br />N/A <br />Traffic Control Plan —Attach TCP if modified <br />Confined Space Entrv—Attach Confined Space Permit <br />Uncontrolled Enercv—Attach Lockout Taqout <br />Doom Truck Used —Attach Lift plan if needed <br />Overhead liflina—Ins ect rigoincl before each use <br />Electrical Hazards & Controls <br />❑ Overhead ❑ Underground ❑ Generator <br />❑ Permanent Wiring <br />Hot Woik—Describe <br />Hazardous Materials Used <br />Falls over 4 fee; —Controlled by: <br />Excavatior Entry gver 3 I feet deep n <br />Final Depth t4d Width( _ <br />❑ Finn Form ❑ Sloping ❑ Trench Box <br />Length <br />❑ Build -a -Box <br />First Aid Equipment/Training/Fire Extinquisher Must be Current <br />Utilities Located: Water (blue) over (red) <br />as vellowl ommunication orannel ❑ other <br />Communication with emergency resoonders provided ❑ <br />nadio Dispatch/ ('hone 911 ❑ City Phone 9-911 <br />Personal Protective Equipment inh-vis ad (�es <br />},aring _F/_Whole Body ❑ other <br />Pre -Job Safety Meeting <br />Name <br />Assianment <br />Nane <br />Assignment <br />�'S It e R <br />1iU S� <br />I <br />.Revised 12/12/11 �� <br />